Your Life is Their Toy - Emanuel Josephson

Hospital and Clinic Rackets

Because hospital facilities are often essential for the present-day practice of medicine, "Doc" Simmons and his A.M.A. crew set out to gain for themselves complete control of hospitals throughout the country. But the hospital business is rich and profitable. The A.M.A. was forced to contest control with two powerfully entrenched groups, the American College of Surgeons and the Social Service Trust. Eventually after much maneuvering and many battles, these three groups compromised and divided the hospital into "spheres of influence." In some States these "spheres" have been given legal ratification.

The consequences of their activities to the public and to the rank and file of the medical profession is strikingly illustrated by a story published in the April 13, 1929, issue of the Milwaukee News Sentinel. This report of a survey on hospitals, made among the rank and file of the local medical profession, reads as follows:


"Hospital prices in Milwaukee must come down if a crisis in the welfare of the medical profession is to be averted, many Milwaukee physicians stated. . . .

"'The hospitals have increased their price scale to such an extent that the patient of moderate means has nothing left for the doctor after he has paid the bill,' one well known downtown physician declared. 'These hospitals pretend to be charitable institutions when, in fact they are exacting top prices in a great majority of instances.

"'I am afraid to take a patient to a hospital unless I know he has enough ready money to pay the bill,' this doctor continued, 'In some instances the hospital authorities will reduce the price scale slightly if I make a special plea, and in very rare instances will take a patient free of charge. The usual reductions, however, leave the final bill still exorbitant. Either there is profit in hospital operations in Milwaukee or there is gross mismanagement'

"Physicians spoke frankly of their grievances when assured anonymity, but shut up like clams when asked to discuss the situation publicly.

"'I cant afford to get in bad with the hospitals at this time', one physician with a large practice said. 'The hospitals in this city are able to run things their own way.'

"This physician produced a bill which had been rendered one of his patients for two days' hospital care. The bill was for $30 but had originally been made out for $37.

"'Here is an example,' he said. 'This patient underwent a simple operation. When I pleaded with the authorities to cut the bill because of the patient's poverty, it was reduced $7. You can't tell me that the hospital didn't make money at the $30 rate. I could have hired a hotel room and a nurse and performed the operation in a hotel for that price.'"

The item of cost of hospitalization the quoted doctors considered primarily from the viewpoint of their own incomes, though it obviously affected in equal measure the purses of their patients. In many communities, since then, the problem of the cost of hospitalization apparently is solved in part by the adoption of group hospitalization plans. But the public is confronted by many rackets that have been developed in connection with hospitals, that affect what is more important than money—the patient's health and life.

The patient is not in the average hospital long before he senses that there is something radically wrong about its organization that vitally affects him. He may sense it in the restriction in his choice of a physician to the members of the hospital's staff, in the high fees that are exacted from him, in the attitude of indifference often shown to his comfort, convenience or even vital needs. He and his friends may regard these as fancied or imagined; but they are very real. They are inherent in the character conferred upon hospital organization by the groups that have gained control over it.


The sphere of influence of the social service group is agitation for the construction of public hospitals, financing and construction of the quasi-public or "voluntary" hospital, and the management of the business of both. The organization, construction and operation of voluntary hospitals and clinics is usually a very lucrative business for the moving spirits if sufficient voluntary contributions can be obtained.

The first step taken by the social service group to get a new hospital, or a new building for an old hospital, is to raise the cry of "overcrowded hospitals and clinics." It is a simple matter to bring about overcrowding even in communities with an excess of hospital facilities by the methods which will be described later. The control and censorship of the press which the social service forces have built up, insure ample publicity and protect them against any contradiction by informed persons. They also control the flood-gates of charity and philanthropy and can divert such funds as they choose.

The next step in the procedure generally is a joining of forces of the social service clique with a group of business men who are prospective directors, and a small group of doctors who are prospective consultants. Usually the members of the group contribute some capital or secure donations to the enterprise. This money may be invested in an old building or a plot of ground. Not infrequently the owner of an otherwise unsaleable property is the moving spirit in the enterprise and a true philanthropist the prime "sucker."

With this nucleus, the entrepreneurs then bend their efforts to impress upon the community their charitable intent and public spirit. This is requisite under the social service laws of most States for the permit to operate a clinic or voluntary hospital or to "beg and solicit funds" bequests and endowments from the public. The law of New York State, for instance, provides that no hospital supported by public subscription may be operated for acknowledged profit.

With the accompaniment of a publicity campaign, solicitation of funds from the public is instituted by volunteers and by highly paid solicitors. Commissions of fifty percent and expenses to soliciting publicity firms are not unusual.

The fraction of the funds donated by the public that is left over by the collectors is turned over to the directors. The disposition of the money in their hands depends upon the wishes of the individual board of directors. Seldom, almost never, is any public accounting ever made of the funds.

The campaign of solicitation of funds may continue for years. There are many instances of collection of millions of dollars from the public for the erection and equipment of hospitals that could not conceivably cost a small fraction of the moneys that have been collected for them.

What happens to these millions contributed by the public which never find their way into the building and operation of these hospitals? Even on superficial examination of the situation it becomes apparent that these hospital funds are either inefficiently dissipated or grossly misappropriated.

Many hospital groups readily confess to dissipation of funds. Such a confession by a prominent hospital executive, was published in the Saturday Evening Post several years ago. Those who are most intimately acquainted with the financial operations of hospitals are inclined to attribute these protestations as pleas to the lesser offense, in order to escape indictment on the greater.


Accountants have informed the writer that on many occasions they find in audits of hospitals obvious evidences of diversion or misappropriation of funds. These generally redound to the credit of firms in which "professional" hospital directors have an interest. These "professionals" shield their activities behind the fronts of reputable fellow directors who adorn the board; and they engineer their pilfering of hospital funds with impunity and skill. They retire from business and devote themselves to the vocation of hospital director, and wax rich on their loot.

A stir was created in New York City a number of years ago when a group of directors of Mount Sinai Hospital spent much money and effort to bar contributor-members from any vote in the management of the hospital. Bills were passed at Albany and appeals made to the courts of the State.

The auditor of one hospital supported by an alien group had among its directors a shrewd brewer who contributed heavily. He suspected diversion of the hospital funds and had called in an auditor in the guise of an efficiency expert. The auditor had no difficulty in discovering the diversion of funds.

"I could save half the cost of operating the hospital," he told me, "but my hands are tied. The hospital, for instance, pays ten cents a dish for the crockery used in the wards. I could buy the identical dishes in the open market for two cents a dish; but I am barred from so doing. All the dishes used in the hospital are bought from Mr. H____ who is on the board of directors,"

Mr. H_____ was a brewer who had turned bootlegger, invested in commercial concerns during prohibition, and made a bit on the side as professional hospital director.

This auditor eventually learned too much. Rather than let his dangerous knowledge wander in paths out of their control, the directors made him superintendent of the hospital at an attractive salary.

The job of hospital architect is extremely lucrative, especially if the architect happens also to be superintendent. Millions have been made in this fashion.

No field is more profitable than hospital construction. Contractors have been known to donate out of their profits as high as a quarter of a million dollars to a hospital, on the directorate of which they sat, for the privilege of constructing a single building for that hospital. In New York City, hospital construction in one year may mount to forty millions, and is seldom less than ten millions.

Hospital and clinic construction have proved profitable for some of the social service clan. One of the most prominent workers in the field of hospitals and clinics who is also head of that division of a rich philanthropic foundation, is a silent partner in a firm which engages extensively in hospital and clinic construction.

Hospital accounts are generally not available for the inspection of the contributing public. If they were, numerous startling items would be discovered. One hospital recorded in its books the payment of six hundred dollars per dozen for cotton sheets for use on its wards. Another recorded expenditure of one hundred and twenty-five dollars for several thousand envelops; and a total stationery bill of tens of thousands of dollars, all paid to the firm of a director. Hospitals are big business for the merchants who control their purchases even when merchandise is honestly priced.


When the hospital is constructed, it becomes the duty of its social service clique to build up business and income. Many devices are unscrupulously employed in this process. Though a hospital is by its very nature a self-advertising business, intensive advertising and publicity are usually used for this purpose.

As has been related, high priced publicity men are employed by hospitals to aid in building up their businesses and those of their staffs. Sometimes the publicity is centered about one or a group of staff physicians or surgeons whose "great deeds" are exploited. In other cases, the publicity centers about the hospital's specialty or some discovery, real or bogus.


Clinics—free municipal, so-called "charitable," or pay—are the most effective bait for hospital business. Their services are represented to the public, falsely, as superior to those of the self-same rank and file of the medical profession who man them. Until the clinic is crowded and overtaxed, all comers are welcomed.

The 1927 report of the group of social service agencies combined in the United Hospital Fund of New York City stated that one and a quarter million people, or one in every five of the population of the city, were treated in the clinics of the city. The incidence of serious disease, requiring medical care, does not average over fifty percent per annum of the populace. It therefore becomes apparent that about half of the sick of New York City were treated in its "charitable" clinics.

These figures are striking, in view of the prosperity of those times. The purchase of luxuries then ran higher than ever. The average New York family boasted automobiles, radio sets, permanent waves, tickets to fights, and bootleg liquor.

Most folks at that time would have resented the imputation that they were poor. They were receiving higher wages than ever before. Automobiles were frequently traded; and when in need of repair they were entrusted, circumspectly, only to highly paid skilled mechanics; for autos were valuable and costly.

These same folks parked their cars as closely as numerous other autos, with the same destination, would permit. They took their own bodies into the crowded clinics for "free" or "cheap" medical care. It is obvious that folks place a low value on their lives as compared with their automobiles. For they would not dream of entrusting their cars to cheap services of the type that they sought for their own bodies.

Even in those days of prosperity medical panhandling had attained vast proportions. Few were the clinics which had not on their lists patients earning between fifty and one hundred and fifty dollars per week, who asserted that they could not afford to pay for medical services. The prevalence of medical panhandling was given official recognition by Dean William Darrach in his report on the Columbia-Presbyterian Medical Center, in the year 1927. He announced that panhandlers applying for services at the clinics of the Center would be compelled to pay the physician rendering services.

Several years later, Miss Dwight, a social service executive of the Center, explained to me the barriers against "panhandlers" set up by the overcrowded Vanderbilt Clinic. The patients were classified in three groups, and dealt with accordingly. Group A could pay the full clinic fee and were admitted without further question unless it was discovered that they could afford to pay high fees for private medical attention; and in this event they were turned over directly to one of a specially privileged group of doctors who maintained their private offices on the premises of the Center. Group B could pay only part of the fee immediately, and the balance at a later date; and they were admitted with discretion. Group C could not pay any part of the high clinic fee; and except for a few who were of special interest for teaching purposes, none was admitted, but all were referred to free municipal clinics. With the advent of government paid Relief, the procedure was modified. This demonstrates the charitable spirit of hospital social service, which serves in voluntary hospitals primarily as a collection agency.

Some of the patients who are lured into the clinics are sent into the hospital to fill its beds and provide for it a revenue. Even in the municipal hospital, the clinics of which are free, all patients who can possibly do so, are compelled to pay for their hospitalization. By thus filling the clinics and hospitals, the social service workers earn their livelihood; for they are well paid out of hospital funds. The number of jobs increases with the number and size of the hospitals and clinics, and salaries rise in proportion to the revenues of institutions.


The American Medical Association and the American College of Surgeons share the monopolistic control of the medical and surgical business of hospitals. Their initial antagonism has resolved itself. The members of the A.C.S. are all members of the A.M.A. whose prime interest is monopoly and protection of the surgical business of the hospitals. The A.M.A. seeks and usually secures for its bosses, control of all the facilities of hospitals.

The organization of this monopoly of clinics and hospitals is elaborate. Every phase is designed to concentrate into the hands of the members of the Association exclusive control of the use of the facilities of all the hospitals and clinics of the country; and into the hands of its bosses and ruling cliques, all lucrative medical and surgical business. The American College of Surgeons yields to the A.M.A. in all matters except the control of the surgical business. It is a powerful Surgical Chamber of Commerce that protects the business of its members from any type of encroachment.

The first step in the upbuilding of this monopoly was to gain absolute control of all existing clinics and hospitals and of the advertising, publicity and business-building forces that are "inherent in clinics. Originally all clinics were private affairs. They consisted of hours set aside by physicians for the treatment of patients who could not afford to pay full fees for medical services. During these hours, the physicians treated those patients privately in office or home, for nominal or no fees. This was the doctor's charity rendered directly to members of the community.

Prior to 1890, a large number of physicians conducted such private clinics in all parts of the country. Today they survive only in the West. A number of physicians acquired fame and large and lucrative practices through the medium of private clinics. In the Eastern States, this inflamed the greed of groups of merchants-in-medicine who were steeped in the tradition of medical "big-business." To monopolize the advertisement and the business-drawing powers of the clinics, they placed on the statute books of a number of states, including New York, laws which outlawed private clinics and permitted only clinics organized with lay boards of directors and with the sanction of the "welfare" officials.

These laws placed the clinics squarely in the control of social service groups and of medical merchants allied with them. The unscrupulous physicians guaranteed themselves even greater benefits than they had derived from their private clinics. They appointed themselves bosses or "chiefs" of the "reorganized" clinics. As their part of the agreement, the social service gentry undertook to build up the business of the clinics and their "chiefs,"


Through this arrangement, these merchant physicians gained for themselves and their hospitals a monopoly of the most direct, intensive and lucrative forms of advertising and "steering" of medical business. Patients are lured to the clinics and hospitals by publicity and advertising. From the clinics they are steered into the private offices of the clinic doctors. In some clinics this solicitation and steering is done openly, bluntly and directly, as at the Columbia-Presbyterian Medical Center's Vanderbilt Clinic, where the patients are led by the hand directly to favored doctors who maintain offices on the premises of the Center. These physicians are "in excellent position to secure inordinately high fees.

Thus the late Dr. John Wheeler refused to see privately a patient who would not pay him in advance a minimum fee of twenty-five dollars per visit. With the aid of the cleverly engineered publicity centered about the King of Siam, whom his operation left blind, the Eye Institute at the Center has levied an enormous toll on the public.

In the majority of clinics, the process of dragging patients into their doctors' private offices is not so direct, but is done by clinic card advertising. These clinic cards are issued to the patients to be preserved under the penalty of a fee for issuance of a duplicate. They bear the names and rank of the clinic physicians; the rank is frequently emphasized by larger and more legible type. Some clinic cards also bear the addresses of the physicians.

In some of the clinics, the name of the chiefs of clinics appears alone on the clinic cards, and patients are steered only into their offices. In others the direct solicitation of patients is prohibited. But this is circumvented through the device of solicitation of patients by employees, such as porters, who work in cahoots with the chiefs of clinics or by solicitors.

There is nothing hit-or-miss about the clinic advertisements. They go directly to patients who are suffering from diseases. They are tantamount to straightforward invitations to the patients: "Come to our private offices if you want superior treatment and if you can afford to pay our fees."

Nevertheless these doctors pretend that they do not advertise. And their "code of ethics" alleges that these advertisements are not advertisements. It has been aptly written by Dr. A. L. Wolbarst:— "while this rule (prohibition of advertisement and publicity) is made to apply by the County Medical Society and the governmental authorities to the modest practitioner, it does not seem to affect some of the leading members of the profession who somehow manage to bask in the light of profitable publicity with no detriment to their 'ethical standing."


Most vital in the monopoly of medical and surgical business is the control of the hospitals of a community. People inevitably discover that the physician who is barred from effective utilization of hospital facilities usually cannot serve them with complete efficiency. This is not due to lack of capabilities of the physician. It is due to the need for hospital facilities in the care of the patient. As a consequence, the physician who is barred from access to hospitals can be throttled and his competition destroyed. Destruction of competition, monopoly of medical advertising and publicity, monopoly of the surgical and medical business of communities, and the maintenance of prices, especially for surgery, at a high and exorbitant level are the prime objects of the "closed hospital" system.

There is no more efficient way of advertising the services of a physician or surgeon than to let it be known to the community that Dr. Skinem, for instance, controls its hospital; that to secure medical or surgical services in the hospital (often even to get into the hospital) it must go to Dr. Skinem and pay him whatever price he may choose to ask. It matters not whether Dr. Skinem is a mediocrity and has bought or wheedled his way into control, or whether he is competent and has earned his position; for the people who are dependent upon the hospital he is the surgeon to whom they must entrust their lives. His name is bandied about on every lip. His successes survive, because or in spite of his services, to sing his praise. His failures damn him; or they die and are buried, and dead men do not talk. In any event the community must come to him, for he controls its hospital. His patients multiply so fast that he scarcely has time to glance at them before ripping open their bellies or snatching out their tonsils. He waxes rich and powerful through his control of the hospital; and eventually puts out of the running his less fortunate colleague whom he bars from the hospital.


The most important device in establishing a monopoly of hospital facilities of the country is the "closed hospital." The "closed hospitals" are private medical monopolies for the exploitation of the public. In them the privilege of the use of facilities which have been provided by the generosity of the public is restricted exclusively to small cliques of physicians whose objective it is to make the greatest possible profit out of their monopolies. This is equally true of both categories of "closed hospitals" the municipal, that are entirely supported by public funds, and the "voluntary" that are supported largely by voluntary contributions of the public.

Thus the "closed hospital" system is the basic and the most vicious hospital racket. These hospitals operate primarily for the aggrandizement of small, self-perpetuating groups of physicians and lay directors, and consistently betray the interests of both the profession and the public.

The "closed hospital" medical staffs are dominated by groups of attending physicians and surgeons, chiefs of staff. The profits to a chief of the control of a hospital service may run very high from the business which it steers into his private practice. The position of chief in a larger metropolitan hospital, such as the Columbia-Presbyterian Medical Center, or Mt. Sinai, or Roosevelt Hospital, may mean the power to gouge patients enough to earn a quarter of a million to a million dollars a year. The struggle for this swag is naturally ruthless.


The chief of staff is boss of hospital and clinic, and autocratic dictator in his realm. He is subordinate only to the social-service-dominated administration, the lay board of directors. If the hospital is "approved" by the A.M.A. or the American College of Surgeons, the chief of staff must also accept orders from those organizations.

Subject to these limitations, the position of chief is hierarchical. His whims and desires are laws. The chief dictates what physicians in the community shall be permitted to use the hospital's facilities for the care of his patients, and what they may do. He dictates what methods of treatment shall be used. He dictates who shall be promoted in rank, and who shall be ousted and denied the use of the hospital facilities.

Staff positions in "closed hospitals," though they carry no direct emolument, are eagerly sought by the medical profession. The hospital is in itself an advertisement of medical services that lures medical business; a place on the staff of the hospital may mean to the physician a share in the monopoly of the advertisement, or of the business, or of both.

Staff positions are rarely obtained solely on the basis of merit. They are sometimes obtained by mediocrity and plodding years of service in menial capacity. In this event the doctor may serve the institution for many years before he is permitted access to the use of the facilities of the hospital for his patients. Usually staff positions are secured by physicians for "considerations." Nepotism or politics may suffice in some cases.


Staff appointments are most usually a matter of direct or indirect purchase. It is quite common practice for staff positions in hospitals to be bought and sold on the open market. The prices paid by doctors to render services without direct pay, to the hospital and clinics are sometimes surprisingly high, until one considers the indirect profits. The doctor who pays the highest price as a rule receives the staff appointment without regard to qualifications.

Dr. Louis I. Harris, former Health Commissioner of New York City, commented on this widely recognized matter as follows:

"I know a number of men who stand firmly entrenched in some closed hospitals and some of them contribute much to scientific knowledge.

"On the other hand, I know some who could not stand scrutiny in a light that would reveal them honestly.

"Some of them are men who have acquired much material wealth or influential connections which apparently have helped them secure positions in hospitals."

It is not unusual for the position of chief of staff of a hospital connected with a medical school, which carries with it the rank of professor," to sell for sums as high as twenty-five thousand dollars or more. It was common practice in the post-graduate medical schools of the country, such as the College of Physicians and Surgeons, (subsequently incorporated into the University of Illinois) to give the appointee stock for the money paid in.

Whether the purchase of staff position ensures any permanence of tenure of office depends entirely upon the extent or lack of principle and honesty of the members of the lay and medical board of directors. It is common practice in hospitals in New York City to demand of the members of the staff that they repurchase their positions at intervals. These intervals depend upon the rate of diversion of hospital funds by the board. The gouging and extortion perpetrated upon the members of the medical staff of these hospitals is sometimes outrageous.


This traffic in hospital appointments has been highly developed by the social service dominated hospital managements. Some hospitals could be operated profitably if they had no other source of income than that derived from appointment of physicians to staff positions. Whenever the cliques who operate the hospitals want to get themselves more funds, they demand from the doctors on their staffs additional contributions. Thus out of a clear sky, in the middle of the summer of 1932 the vacationing members of the staff of Bronx Hospital, of New York City, received telegrams informing them that they must immediately contribute one thousand dollars to the hospital if they wished to retain their staff positions.

A favorite method of sale of hospital staff positions is through dinners for which tickets must be purchased by physicians or must be sold by them to their friends at extortionate rates. Dinners at costs ranging from twenty-five to one hundred dollars a plate are quite common. The latter rate prevailed for the tickets to the dinners of a Bronx hospital given prior to removal to its new building several years ago. The profession was openly apprized that positions on the staffs of the clinic and the hospital could be bought on the basis of the number of tickets purchased by the physician or sold to his friends. The scale started at five tickets, or five hundred dollars, for a lowly clinic position; and ranged to five thousand, or more, dollars for the position of chief of a hospital staff.

At the Beth David Hospital, of New York City, the price range of the tickets and of the jobs was more modest. The hospital eventually opened after raising large sums over a period of a decade or more for the building which merely cost several hundred thousand dollars when completed.

It is generally the younger, junior physician and the politically lesser fry who are most consistently and extortionately plundered. The requirement of the medical practice acts of several states that a graduate in medicine have one year of hospital internship has proved an excellent device for extortion. It has made the sale of the position of intern a lucrative business for many hospital gangs.


The purchase of a staff position, or its acquisition for other considerations, does not insure promotion or even continued possession. Especially in the hospitals and institutions in which the direct purchase of position is spurned as crude and offensive to the sensibilities of the grafters and racketeers who dispose of appointments, the coin of payment has often become quite debased. The subordinate members of staffs are entirely dependent for their tenure of position upon the whim of their superiors. They must "aim to satisfy."

The superior, the "chief," must be wooed by his subordinates. In exceptional cases they may hold their positions by influence with the board of directors or by social or business position. Otherwise they must hold the superior's good will in any way that it can be held—politics, friendship, service, flattery, purchase or other means.

An absolute requisite for securing and retaining hospital appointments is to build up the medical businesses of the chiefs of staffs of the hospital by sending them patients for operation or consultation. The junior staff member must refer to his superiors, patients who will pay them their high or exorbitant fees, no matter how low may be their professional caliber, if he wishes to retain his appointment.


As a direct consequence of the hierarchic hospital organization, hospital staffs generally are manned by physicians of the most mediocre caliber. Staff members in most instances dare not show exceptional ability or originality for fear of arousing the chiefs' jealousy. If a subordinate happens to make a discovery, even if it be published as usual, under the name of the chief, he has raised suspicion. He is suspect as a menace to the position, reputation and practice of the chief, and he may be ousted on any pretext. If he publishes a discovery without the consent of his chief or of the hospital, even though it contains no reference to the hospital, he is certain to be ousted. Mediocrity fares best in a "closed hospital," For this reason there seldom emanates from any large metropolitan hospital a substantial contribution to medical science.

I recall asking a physician occupying a junior position on the staff of the Manhattan Eye and Ear Hospital why he did not publish an interesting observation that he had made. He replied:

"I do not dare. I would be fired from the staff. During the ten years that I have been connected with the hospital I have published nothing. If I am promoted next year, according to my expectation, I will have attained a position which would make it safe for me to publish."

Sad is the abasement which has been wrought in medical and hospital organization by politics and commercialism. The subjection and subservience of the rank and file of the medical profession to its political hospital bosses is rendered more startling by the fact that in a great majority of cases no emolument, salary or other reward is ever received by them for their services. They live in the often forlorn hope that they may succeed to the job of chief and enjoy its rich rewards.


They are forced to serve by a subtle form of slander of the profession which has been engineered by collusion of hospital organization, social service and organized medicine. It has been bruited about the community that the physician who does not serve in hospitals and clinics is "incompetent and not to be trusted;" that a physician "requires the experience of continuous service in hospital and clinic." The public have come to firmly believe these falsehoods and propaganda. The rank and file of the medical profession are intimidated thus to man the hospitals and clinics even though they derive from them no benefits or compensation.

This practise was brought out into the open in the inaugural address of Dr. Douglas, former president of the New York County Medical Society. He frankly advocated that the rank and file of the profession be forced to man the clinics and hospitals, which could not be run without them. One can sense from this attitude the contempt which the bosses of medicine have for the rank and file of the profession.


Coupled with the propaganda of slander is promotional propaganda to create faith in hospital staffs. In many closed hospitals, especially those catering to clannish and neurotic foreign or religious elements, much publicity propaganda, innuendo, planning, plotting and maneuvering is spent in the effort to induce their public to believe that the mere association with the institution endows the physician with superior virtues and abilities. They treat their colleagues with aloofness and contempt. Among themselves they form clans with the dual purpose of deriding and riding down all colleagues, and of mutually bolstering their reputations and practices.

They are, in reality, medical gangs intent upon fleecing the public. Their tactics, which are a shrewd commercial pose, do not fail to impress their public who gullibly turn to them. Once a patient falls into their clutches, he is bandied to and fro among the clique, often until his purse is drained; then he is cast out. One, or more, such gang can be found in every town or city.

Denial of admission to patients of physicians who are not on their staff even in event of emergency, on the false ground that "there are no beds available," is a contemptible trick regularly used by voluntary hospitals to discredit and penalize physicians who are not on their staffs; and to enhance the reputations and practices of their physicians. Within some hospitals discrimination is exercised in favor of a few of their physicians. The public soon learns that beds are always available for the favored physician. This betrayal of the public is often a telling factor in rivalry for practice.

The fear of being destroyed by adverse propaganda, and the hope of sharing the rewards of staff membership and regularity, make the rank and file of the profession flock to serve the clinics and hospitals in building up their businesses. Through control of these institutions and the rule which bars from their staffs physicians who are not its members, the A.M.A. exerts a powerful control over the country's medical business. The "closed" hospital is fashioned into a device whereby medical overlords rob the rank and file of the profession of their patients and incomes.